When it comes to musculoskeletal (MSK) health, patients often find themselves on a daunting journey filled with pain, uncertainty, and ultimately, disappointment. A mother of two grappling with persistent back pain is steered towards surgical interventions for spinal fusion, which, even after repeated surgeries, leave her with no relief and even more discomfort.1 An orthopedist recommends a patient with a degenerative meniscus tear undergo a $10k knee arthroscopy procedure that is proven to show no additional benefit compared to lower-cost and less invasive nonoperative care, inclusive of physical therapy.2
In both of these scenarios, the outcome was surgery that either failed to produce the desired clinical outcome or was not undertaken based on evidence-based medicine. It also left these vulnerable people to foot astronomical medical bills. Now, let’s be clear—we are not against surgery. Instead, we advocate against inappropriate and unnecessary surgery. Surgery and medical procedures in all disciplines should be used responsibly, namely following evidence-based guidelines and based on shared decision-making with the patient.
The Pitfalls of Traditional Approaches toMSK Health
In the conventional approach to managing MSK health, patients voicing concerns to their primary care provider (PCP) are typically referred for imaging — which is often not diagnostic, but merely reflexive— and consultations with a surgical specialist. From that point, patients are significantly more likely to undergo invasive, costly surgeries. Some research indicates that undergoing X-rays or MRIs of the back, knee, or other joint can significantly increase this likelihood of surgery by a staggering 200–300%.3 This classical approach may leave patients feeling overwhelmed, disempowered, and even entirely disconnected from their own healing process.
The widespread overuse of medical imaging has become pervasive, and is often used to strongly influence (or even determine) clinical decisions without a holistic evaluation of the patient. An apt comparison might be deciding that someone with newly-formed wrinkles needs a facelift based solely on a photograph of their skin. In contrast, a comprehensive consultation with the patient could identify a number of noninvasive, lower cost skin care treatments and procedures to improve their wrinkles.
Orthopedic conditions can often stem from mechanical and functional causes, as opposed to being truly tissue-related issues, which would be identified on imaging studies such as an x-ray or MRI. Research shows that MRI findings of abnormal tissues (e.g., degenerative or arthritic changes, bulging discs) often do not correlate with clinical symptoms.4 5 So using an MRI to diagnose why someone has low back pain is fraught with risk. It’s akin to sending a picture of your car’s engine to your local mechanic to diagnose the source of a strange noise: without having the vehicle physically examined in the repair shop, it’s nearly impossible.
The Importance of Shared Decision-Making
Enter non-operative musculoskeletal medicine and physical therapy to help sort out the confusion. Here physicians and physical therapists expertly trained in the evaluation and treatment of musculoskeletal disorders can use a holistic, evidence-based approach to musculoskeletal care by engaging their patients directly, involving them in the decision-making process, and considering their unique needs and circumstances.
In a more modern and functional approach, the patient should be placed in the driver’s seat of their own care journey. Rather than rushing to surgical interventions, clinicians ought to prioritize therapies that address the root causes of discomfort and promote long-term healing while ensuring that patients truly participate in shared decision-making.
Why is this crucial? Even if patients meet evidence-based criteria for surgery, it’s important to recognize that most orthopedic surgeries are still optional and not necessities. Just as having wrinkles doesn’t automatically mean a facelift is needed, experiencing back pain and arthritis doesn’t always mean surgery is necessary if a patient has exhausted nonoperative, conservative pathways.
Of course, physical therapy cannot repair a fully-torn ligament and surgery has its place in the treatment of musculoskeletal care. Nevertheless, shared decision making around the appropriateness of surgery is critical in such instances, where factors such as the risks associated with surgery and a patient’s desired activity levels should be taken into account. It circles back to the facelift analogy: are we merely treating pictures, or are we fully exploring what truly matters to the patient and ensuring that patients fully understand when surgery is optional?
Shifting Toward Patient Centric Care
We believe it’s time to shift the conversation with patients, ensuring that care plans are truly built with a patient-centric lens. This involves transparent discussions regarding when surgery is an absolute requirement versus an optional consideration. Unfortunately, such conversations rarely occur across the United States.
Our experience suggests that many orthopedic surgeons lack an understanding of how to actually engage in [shared-decision making] or received insufficient communications skills training in medical school and residency. While some physicians can naturally communicate and already incorporate [shared decision making] in patient care, there are still a lot who don’t.
Below, we identify and debunk several myths about Value Based Care (VBC) and MSK health to help illustrate the disparity between standard operating procedures and more holistic, patient-centric care.
Empowering Patients Through IntegratedMSK Care
Our shared goal is to empower patients along with their clinicians with the right resources and technologies to seize control of cost-effective, holistic care opportunities. Our partnership with Vori offers Pearl’s clinical partners and their patients convenient, virtual access to an integrated team of MSK specialists, physical therapists, health coaches, and nutritionists all in one place. The focus is on a comprehensive, 360 degree review of the patient and prioritizing evidence-based care that actually meets the patient’s needs.
By shifting the focus away from invasive surgeries and expensive diagnostic procedures and instead shining the light truly on the patient and meeting their goals, we aim to create a more patient-centered approach to spine and orthopedic health — one of compassion, effective communication, and collaboration. This requires a shift in mindset from the status quo that embraces a continuum of care of PCP and specialty integration. Together, we can alleviate the financial burden of our patients and empower them to reclaim their health and embark on a journey towards a pain-free future.
- Ben Eisler, “Tapping into controversial back surgeries,” CBS News. April 2014.
- Robert H. Shmerling, MD, “Knee arthroscopy: Should this common knee surgery be performed less often?” Harvard Health. April 2020.
- Timothy W. Flynn, PT, PhD, et al., “Appropriate Use of Diagnostic Imaging in Low Back Pain: A Reminder That Unnecessary Imaging May Do as Much Harm as Good,” JOSPT. November 2011
- Richard Kasch, MD, et al., “Association of Lumbar MRI Findings with Current and Future Back Pain in a Population-based Cohort Study,” Spine Journal. February 2022.
- Jeroen C. van Rijn, et al., “Symptomatic and asymptomatic abnormalities in patients with lumbosacral radicular syndrome: Clinical examination compared with MRI,” Science Direct. September 2006.
- “Shared Decision-Making Empowers Patients with Information and Options to Benefit Bone and Joint Care,” AAOS. December 2020.
- A. J. Rana, et al., “A Specialist-Led Care Model: Aligning the Patient and Specialist for the Greatest Impact,” The Journal of Arthroplasty. May 2023.
- B.D. Springer, et al., “Risk Should Not Be a “Four-Letter Word” in Healthcare. Risk and the Future of Musculoskeletal Care,” The Journal of Arthroplasty. September 2023.
- H Miner, et al., “Value-based Healthcare: Not Going Anywhere-Why Orthopaedic Surgeons Will Continue Using Telehealth in a Post-COVID-19 World,” Clinical Orthopedics and Related Research. December 2020.
- C.S. Han, et al., “Low back pain of disc, sacroiliac joint, or facet joint origin: a diagnostic accuracy systematic review,” EClinicalMedicine. April 2023.
- W. M. Hooten, & S. P. Cohen, “Evaluation and Treatment of Low Back Pain: A Clinically Focused Review for Primary Care Specialists,” Mayo Clinic Proceedings. December 2015.
- Vicky Duong, et al., “Evaluation and Treatment of Knee Pain: A Review,” JAMA. October 2023.
- Shubha V Srinivas, et al., “Application of “less is more” to low back pain,” Arch Intern Med. July 2012.
- Tyler J. Loftus, MD, et al., “Artificial Intelligence and Surgical Decision-making,” JAMA. December 2019.
- Ravi S. Nunna, MD, et al., “The Risk of Adverse Events in Smokers Undergoing Spinal Fusion: A Systematic Review and Meta-Analysis,” Global Spine Journal. November 2022.
- Shreyasi Deb, PhD, MBA & Alix Braun, MPH, “A Collaborative Approach Can Improve Value-based Care,” AAOS. November 2023.
